Prosthesis having pivoting fenestration

ABSTRACT

An endoluminal prosthesis system includes a tubular graft having a pocket on the exterior of the graft. The graft further includes a wire extending within a lumen of the graft, with the wire extending through the passageway and into the pocket. An extension prosthesis can be inserted over the wire and into engagement with the pocket and the passageway, where the extension prosthesis can be sealed with the pocket and the passageway to seal the otherwise unused passageway in the graft.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional Application No. 61/746,038, filed Dec. 26, 2012, which is hereby incorporated by reference in its entirety herein.

TECHNICAL FIELD

This invention relates to endoluminal medical devices for implantation within the human or animal body for treatment of endovascular disease. U.S. patent application Ser. No. 10/962,632, filed Oct. 12, 2004, Ser. No. 12/548,120, filed Aug. 26, 2009, and Ser. No. 13/213,349, filed Aug. 19, 2011, are hereby incorporated by reference in their entirety.

BACKGROUND OF THE INVENTION

The functional vessels of human and animal bodies, such as blood vessels and ducts, occasionally weaken or even rupture. For example, the aortic wall can weaken, resulting in an aneurysm, or it may develop a tear in one of the layers of the aortic wall resulting in an aortic dissection.

One common surgical intervention for weakened, aneurysmal or ruptured passageways or ducts involves the use of an endoluminal prosthesis to provide some or all of the functionality of the original, healthy passageway or duct and/or preserve any remaining vascular integrity by replacing a length of the existing passageway or duct wall that spans the site of failure or defect. Endoluminal prostheses may be of a unitary construction or may be comprised of multiple prosthetic modules. They also may be a single tubular device or a bifurcated branching device depending on the desired application.

In many cases, however, the damaged or defected portion of the vasculature may include a branch vessel branching from the main vessel. For example, in the case of the abdominal aorta, there are at least three major branch vessels, including the celiac, mesenteric, and renal arteries, as well as other others, leading to various other body organs. Thus, when the damaged portion of the vessel includes one or more of these branch vessels, some accommodation must be made to ensure that the prosthesis does not block or hinder blood flow through the branch vessel. In many instances, there may in insufficient healthy tissue in the aorta near the branching vessels adequately seal a prosthesis without partially or completely blocking one or more of the branching vessels.

In some cases, a patient's anatomy may not include, for example, a renal artery one side, or it may not be possible to cannulate one of the renal arteries. These conditions can result in an unused passageway of the prosthesis intended for use with a typical renal artery in the area of the unused passageway. These passageways can be closed using endovascular plugs or other devices. Alternatively, the prosthesis can undergo “back table” modification, wherein the prosthesis is deployed from its sheath, a patch can be sewn over the passageway, the prosthesis is re-sheathed, and then the prosthesis can be implanted using known methods. In another alternative, a custom device can be made to conform to the patient's unique anatomy. These solutions, however, are undesirably labor intensive or costly.

SUMMARY

A prosthesis system is provided, comprising: a graft having a tubular body with a proximal and distal end, a lumen between the proximal and distal ends, and a surface comprising a first biocompatible material; at least one passageway extending through a sidewall of the graft; a pocket disposed on an exterior surface of the graft, the pocket having a cavity and an opening open to an exterior of the graft; and a wire extending through the lumen of the graft and through the passageway out of the lumen and into the pocket cavity.

In another form, the system further comprises a tubular extension prosthesis extending between the pocket and the passageway, wherein the tubular extension prosthesis sealingly engages the passageway and the pocket.

In another form, the pocket comprises the first biocompatible material.

In another form, the pocket is oriented longitudinally along the graft.

In another form, the pocket opening faces the passageway.

In another form, the pocket is oriented transverse to a longitudinal axis of the graft.

In another form, the wire extends through the graft material into the graft lumen at a location within the pocket cavity.

In another form, the system further comprises an inner stent ring attached to an inner surface of the tubular graft, wherein the pocket is disposed distally from the inner stent ring.

In another form, the passageway comprises a pivot fenestration.

In another form, a system for sealing an unused passageway in a graft is provided, the system comprising: an expandable tubular graft having proximal and distal ends and a lumen between the proximal and distal ends; at least one passageway extending through a sidewall of the tubular graft; a pocket attached to an external surface of the tubular graft; a wire extending through the lumen and through the passageway out of the lumen and into the pocket; and an expandable tubular branch extension disposed over the wire between the pocket and the passageway.

In another form, the tubular graft includes a sealing portion at the proximal end.

In another form, the pocket is disposed on a portion of the graft separate from the sealing portion.

In another form, the pocket is disposed at least partially over the sealing portion.

In another form, the tubular branch extension is expanded into sealing engagement with the pocket and the passageway.

In another form, the tubular branch extension sealingly engages the pocket and the passageway and the pocket and tubular branch extension are substantially crushed.

In another form, a method for sealing an unused passageway in a tubular prosthesis is provided, the method comprising: delivering a tubular graft to a body vessel, the tubular graft having proximal and distal ends and a lumen between the proximal and distal ends, the graft further having a passageway in a sidewall thereof, a pocket disposed on an exterior surface of the graft, the pocket having a cavity, and a wire extending through the lumen of the graft and out of the lumen through the passageway and into the pocket cavity; delivering an expandable tubular graft extension along the wire toward the pocket; engaging the tubular graft extension with the pocket and the passageway; expanding the tubular graft extension; and sealing the tubular graft extension to the pocket and the passageway.

In another form, the method further comprises withdrawing the wire from the pocket through the tubular graft extension.

In another form, the method further comprises, in response to sealing the tubular graft extension to the pocket and the passageway, crushing the pocket and graft extension.

In another form, the pocket is disposed proximally from the passageway.

In another form, the pocket and the wire are aligned transverse to a longitudinal axis of the tubular graft.

The foregoing paragraphs have been provided by way of general introduction, and are not intended to limit the scope of the following claims. The presently preferred embodiments, together with further advantages, will be best understood by reference to the following detailed description taken in conjunction with the accompanying drawings.

BRIEF DESCRIPTION OF SEVERAL VIEWS OF THE DRAWINGS

FIG. 1 shows a perspective view of a fenestrated prosthesis having pivotable fenestrations concave (internal) pivotable fenestrations;

FIG. 2 is a partial and internal view of the prosthesis of FIG. 1;

FIG. 3 shows a perspective view of a fenestrated prosthesis having pivotable fenestrations convex (external) pivotable fenestrations;

FIG. 4 is a partial and internal view of the prosthesis of FIG. 3;

FIG. 5 shows another fenestrated prosthesis having pivotable fenestrations concave (internal) pivotable fenestrations;

FIG. 6 is an enlarged perspective view of the pivotable fenestration shown FIG. 5;

FIG. 7 shows a fenestrated prosthesis having imageable markers and reinforcement frames;

FIG. 8 is another partial and internal view of an internal pivotable fenestration;

FIG. 9 is a partial, cross-sectional view of a portion of a prosthesis having a pivotable fenestration;

FIG. 10 shows an interior view of a pivotable fenestration where the fenestration is disposed within the lumen of the prosthesis;

FIG. 11 shows an exterior view of a pivotable fenestration where the fenestration is disposed within the lumen of the prosthesis;

FIG. 12 is a prosthesis having a protrusion of graft material to form a fenestration and an extension;

FIG. 13 is a fenestrated prosthesis that has been deployed within a diseased vessel, such as the aorta, where branch vessel prostheses are deployed within the branch vessels;

FIG. 14 shows a branch vessel prosthesis deployed in a secondary branch vessel, where the branch vessel prosthesis is deployed in a right branch vessel positioned lower than its corresponding left branch vessel;

FIG. 15 shows a branch vessel prosthesis deployed in a secondary branch vessel, where the branch vessel prosthesis is deployed in a right branch vessel positioned higher than its corresponding left branch vessel;

FIG. 16 shows an alternative embodiment of a graft having a pocket disposed adjacent a fenestration therein;

FIG. 17 shows branch extension prosthesis engaged between the pocket and the fenestration;

FIG. 18 shows the pocket oriented longitudinally along the graft;

FIG. 19 shows the pocket oriented transverse to the longitudinal direction of the graft; and

FIG. 20 shows the graft implanted with the body vessel of a patient, with one artery of the patient cannulated using a branch extension prosthesis, and another artery non-cannulated with a branch extension prosthesis extending between the fenestration and the pocket.

DETAILED DESCRIPTION

The present disclosure relates to an endoluminal prosthesis, such as a stent graft that includes one or more fenestrations to accommodate endovascular disease, such as an aneurysm in cases where one or more side branches is involved, and a side branch prosthesis is deployed within the fenestration to permit fluid flow from the endoluminal prosthesis into the branch vessel. The prosthesis includes fenestrations that pivot as needed to accommodate the dynamic geometry of the aortic branches. In various aspects shown and described in more detail below, for example, one or more pivotable fenestrations provided on a prosthesis lie outside the surface plane of the body of the prosthesis and will allow a branch vessel stent, graft or stent-graft that has been placed in the fenestration to pivot into a variety of orientations required to meet and seal the branch vessel device in the branch vessel. The orientation of the fenestrations may dynamically change over time as needed by changing anatomy.

Definitions

Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood to one of ordinary skill in the art to which this invention belongs.

The term “distal” means a location or direction that is, or a portion of a device that when implanted is further downstream in the direction of or with respect to blood flow.

The term “proximal” means a location or direction that is, or a portion of a device that when implanted is further upstream in the direction of or with respect to blood flow.

The term “fenestration” means an opening provided through a surface of a prosthesis from the interior of the prosthesis to the exterior of the prostheses and may have a variety of geometries, including circular, semi-circular, oval, oblong, as well as other geometries.

The term “biocompatible” refers to a material that is substantially non-toxic in the in vivo environment of its intended use, and that is not substantially rejected by the patient's physiological system (i.e., is non-antigenic). Examples of biocompatible materials from which textile graft material can be formed include, without limitation, polyesters, such as polyethylene terephthalate; fluorinated polymers, such as polytetrafluoroethylene (PTFE) and fibers of expanded PTFE, and polyurethanes. In addition, materials that are not inherently biocompatible may be subjected to surface modifications in order to render the materials biocompatible. Examples of surface modifications include graft polymerization of biocompatible polymers on the materials surface, coating of the surface with a crosslinked biocompatible polymer, chemical modification with biocompatible functional groups, and immobilization of a compatibilizing agent such as heparin or other biocompatible substances. Thus, any fibrous material having sufficient strength to survive in the in vivo environment may be used to form a textile graft, provided the final textile is biocompatible. Fibers suitable for making textile grafts include polyethylene, polypropylene, polyaramids, polyacrylonitrile, nylon, and cellulose, in addition to the polyesters, fluorinated polymers, and polyurethanes as listed above. Furthermore, bioremodelable materials may also be used singly or in combination with the aforementioned polymer materials. The textile may be made of one or more polymers that do not require treatment or modification to be biocompatible. The graft may be constructed from woven multifilament polyester, for example and without limitation, Dacron™, produced by DuPONT. Dacron™ is known to be sufficiently biologically inert, non-biodegradable, and durable to permit safe insertion inside the human body.

The term “prosthesis” means any device for insertion or implantation into or replacement for a body part or function of that body part. It may also mean a device that enhances or adds functionality to a physiological system. The term prosthesis may include, for example and without limitation, a stent, stent-graft, filter, valve, balloon, embolization coil, and the like.

The term “tubular” refers to the general shape of an endoluminal device which allows the module to carry fluid along a distance or fit within a tubular structure such as an artery. Tubular prosthetic devices include single, branched, and bifurcated devices. Tubular may refer to any shape including, but not limited to, tapered, cylindrical, curvilinear, or any combination thereof. A tubular device may have a cross-sectional shape that is, circular, substantially circular or the like. However, it should be understood that the cross-sectional shape is not limited thereto, and other shapes, such as, for example, hexagonal, pentagonal, octagonal, or the like are contemplated. The term “endoluminal” refers to or describes objects that can be placed inside a lumen or a body passageway in a human or animal body. A lumen or a body passageway can be an existing lumen or a lumen created by surgical intervention. As used in this specification, the terms “lumen” or “body passageway” are intended to have a broad meaning and encompasses any duct (e.g., natural or iatrogenic) within the human body and can include a member selected from the group comprising: blood vessels, respiratory ducts, gastrointestinal ducts, and the like. “Endoluminal device” or “endoluminal prosthesis” thus describes devices that can be placed inside one of these lumens.

The term “graft” or “graft material” describes an object, device, or structure that is joined to or that is capable of being joined to or implanted in or against a body part to enhance, repair, or replace a portion or a function of that body part. A graft by itself or with the addition of other elements, such as structural components, may comprise an endoluminal prosthesis. The graft may be comprised of a single material, a blend of materials, a weave, a laminate, or a composite of two or more materials. The graft may be constructed from natural or organic materials, for example and without limitation, a biological scaffold or bioremodelable material, such as small intestine submucosa (“SIS”), which is commercially available by Cook Biotech, West Lafayette, Ind. The graft may also be constructed from a synthetic, for example and without limitation, a polymer. The graft may be formed from a single layer or multiple layers of material. In embodiments employing a plurality of layers of material, the layers may remain separate, or may be attached to each other through a secondary process such as sintering, curing, adhesives, and sutures or the like.

The term “stent” means any device or structure that adds rigidity, expansion force or support to a prosthesis. A stent is used to obtain and maintain the patency of the body passageway while maintaining the integrity of the passageway. Also, the stent may be used to form a seal. The stent may be located on the exterior of the device, the interior of the device, or both. A stent may be self-expanding, balloon-expandable or may have characteristics of both. A variety of other stent configurations are also contemplated by the use of the term “stent.” The stents 16 may be comprised of a metallic material selected from stainless steel, silver, platinum, palladium, gold, titanium, tantalum, iridium, tungsten, cobalt, chromium, cobalt-chromium alloy 1058, cobalt-based 35N alloy, nickel-based alloy 625, a molybdenum alloy, a molybdenum alloy including about 0.4% to about 0.8% of lanthanum oxide (Li₂O₃), and a nickel-titanium alloy, such as nitinol, or other suitable materials as known in the art. The stents may be made of a wire, or may be laser or cannula cut, or manufactured by other known methods.

The term “yarn” refers to a length of a continuous thread or strand of one or more filaments or fibers, with or without twist, suitable for weaving, knitting or otherwise intertwining to form a textile fabric.

The term “branch vessel” refers to a vessel that branches off from a main vessel. Examples are the celiac and renal arteries which are branch vessels to the aorta (i.e., the main vessel in this context). As another example, the hypogastric artery is a branch vessel to the common iliac, which is a main vessel in this context. Thus, it should be seen that “branch vessel” and “main vessel” are relative terms.

“Longitudinally” refers to a direction, position or length substantially parallel with a longitudinal axis of a reference, and is the length-wise component of the helical orientation.

“Circumferentially” refers to a direction, position, or length that encircles a longitudinal axis of reference. The term “circumferential” is not restricted to a full 360° circumferential turn or to a constant radius.

The terms “patient,” “subject,” and “recipient” as used in this application refer to any animal, especially humans.

FIGS. 1-8 show a fenestrated prosthesis 10, here a stent graft, having a tubular body and comprising a biocompatible material, having one or more fenestrations 12 pivotable in any direction away from an axis perpendicular to a longitudinal axis of the prosthesis. The pivotable fenestrations 12 have a diameter extending from a sidewall of the graft. The pivotable fenestrations 12 include a first, inner perimeter 26 surrounding the fenestration 12 having a diameter, a band 28 of flexible material attached to and surrounding the first perimeter 26, and a second, outer perimeter 30 attached to and surrounding the band 28 of flexible material. The band 28 of material has a first diameter that is substantially the same as the diameter of the first perimeter 26, and a second diameter substantially the same as the second perimeter 30. The diameter of the band of material decreases in a direction away from the surface 20 of the graft 14 from the second perimeter to the first perimeter. The band of flexible material may include a flexible frame 48.

In some aspects, the fenestrated prosthesis 10 is intended for placement in the abdominal aorta and to accommodate vessels that branch from the aorta, for example, the renal arteries, and into which a branch vessel prosthesis may be placed. However, the fenestrated prosthesis 10 is not limited for use in the abdominal aorta but may be used in other vessels of the body from which other vessels branch, such as the ascending thoracic aorta, the descending thoracic aorta, as well as other body vessels.

FIG. 1 shows a perspective view of a prosthesis 10 that is a stent graft. The prosthesis 10 includes graft material 14 associated with one or more stents 16. The prosthesis 10 has a proximal end 22, a distal end 24, and a lumen 18 extending through the prosthesis 10 to permit passage of blood flow from the proximal end 22 to the distal end 24. The stents 16 may be placed on the external surface 20 and/or internal surface 21 of the graft material 14. In one particular embodiment, the prosthesis 10, such as that shown in FIG. 1, has external body stents 16 a, 16 b, and 16 c, and at least one internal stent 16 d. The internal stent 16 d may be a sealing stent and placed at or near the proximal end 22 of the prosthesis 10 to seal the prosthesis 10 at the proximal end 22 to the walls of a blood vessel into which it has been placed. Additionally, or alternatively, depending on the location of the place of the prosthesis 10 or a particular need, a sealing stent 16 d may be placed at either or both the proximal and distal ends 22, 24 of prosthesis 10. The prosthesis 10 also may include an attachment mechanism, for example, an attachment stent 42, at either or both ends of the prosthesis 10, to further secure the prosthesis 10 within the body vessel and prevent migration of the prosthesis 10.

As shown in FIG. 1, the prosthesis 10 has several openings or fenestrations that extend from the internal surface 21 to the external surface 20 of the graft material 14. The prosthesis 10 of FIG. 1 has two pivotable fenestrations 12, at least one non-pivotable fenestration 38, and a scallop 40. Here, the scallop 40 is placed at the proximal end of the prosthesis 10.

FIGS. 1-8 show various aspects and views of the prosthesis 10 having pivotable fenestrations 12. Pivotable fenestrations 12 have an inner perimeter 26 surrounding the fenestration 12, a band 28 surrounding the inner perimeter 26, and an outer perimeter 30 surrounding the band 28. As shown, the outer perimeter 30 diameter is greater than the band 28 diameter and the inner perimeter diameter 26. The inner perimeter 26, the band 28 and the outer perimeter 30 would be substantially concentric with one another if they were in the same plane, for example the surface plane of the graft. The inner perimeter 26, the band 28 and the outer perimeter 30 may form a hemispherical shape, resembling a dome, or a frustoconical cone extending from the surface of the graft material 14. The fenestration 12 is provided at the peak or top of the hemispherical shape or extension. In other embodiments, the band 28 may comprise a tapered, flexible tube extending from the outer perimeter 30 and the inner diameter 26.

Stents 16, for example those shown in the Figures may be, for example zig zag stents, also known has Z-stents, that comprise a series of struts 32, 34 connected by apices 36, although the type of stent used is not so limited. When Z-stents are used, a portion of the outer perimeter 30 of one or more of the fenestrations 12 may lie between adjacent struts 32, 34 of one of the stents 16. The stents 16 may be either self-expanding or balloon expandable. Preferably, they are self-expanding. However, a combination of self-expanding and balloon expandable stents also may be contemplated.

As set forth above, the stents 16 include struts 32, 34 that are spaced apart from each other. The strut spacing is measured from bend-to-bend (or apex to apex 36). Stent amplitude, spacing and stagger are preferably optimized for each prosthesis design. In some aspects, the apices or bends 36 of the struts 32, 34 may be staggered for minimal contact with each other. As shown in FIG. 1, the stents 16 a, 16 b, 16 c are positioned adjacent each other and the apices 36 of each row are in circumferential alignment with the bends of longitudinally adjacent rows. In other aspects, as shown in FIG. 5, every bend 36 of each row may be in substantial circumferential alignment with the bends 36 of longitudinally adjacent rows.

The pivotable fenestrations 12 may be located within the lumen 18 of the prosthesis 10 or extending from the exterior of the prosthesis 10. In the first aspect, the pivotable fenestrations 12 may be said to be concave, relative to the external surface 20 of the graft material 14. In the second aspect, the pivotable fenestrations 12 may be said to be convex, relative to the external surface 20 of the graft material 14. FIG. 1 shows the pivotable fenestrations 12 located internal to the prosthesis 10, that is, they lie within the lumen 18 of the prosthesis 10. In the particular aspect shown in FIG. 1, the pivotable fenestrations 12 reside substantially on one side of the prosthesis 10 and are adjacent to one another. In the aspects shown in FIGS. 3-4 and 7-8, the pivotable fenestrations 12 are positioned to align with, for example, the renal arteries. In other aspects, the one or more pivotable fenestrations 12 may be positioned to align with other branch arteries throughout a diseased vasculature. Additional fenestrations and scallops as disclosed here may also be included.

FIG. 2, which is a partial internal view of the prosthesis 10 of FIG. 1, shows a view of the prosthesis 10 looking into the lumen 18 of the prosthesis 10 from the proximal end 22. As shown, pivotable fenestrations 12 extend or protrude into the lumen 18. Pivotable fenestrations 12 have an inner perimeter 26, a band 28, and an outer perimeter 30. As shown in FIG. 2, the outer perimeter 30 lies substantially flush (in the same plane) of the graft material 14, and the band 28 and the outer perimeter 30 form a hemispherical shape, such as a dome or frustoconical cone extending into the lumen 18. Although both the first and outer perimeters 26, 30 are shown as substantially circular, they may be oval, oblong or some other desired geometric shape.

FIGS. 3 and 4 show an aspect of a prosthesis 10 having externally extending pivotable fenestrations 12. FIG. 3 shows a partial view of a prosthesis 10 having two externally extending pivotable fenestrations 12 extending form opposite sides of the prosthesis 10. As with the other aspects, the fenestrations 12 have an inner perimeter 26 surrounding the fenestration, a band 28 of material surrounding the inner perimeter 26, and an outer perimeter 30 surrounding the band 28 of material. FIG. 4, which is a partial internal view of the prosthesis 10 of FIG. 3, shows a view of the prosthesis 10 of FIG. 3, looking into the lumen 18 of the prosthesis 10 from the proximal end 22. As shown, pivotable fenestrations 12 extent or protrude away from the external surface 20 of the graft material 14. The outer perimeter 30 lies substantially flush (in the same plane) of the graft material 14, and the band 28 and the outer perimeter 30 form a hemispherical shape, such as a dome, or frustoconical cone extending into the lumen 18.

FIGS. 5 and 6 show further aspects of a fenestrated prosthesis 10 having at least one pivotable fenestration 12. FIG. 5 shows a prosthesis 10 that is a stent graft. The prosthesis includes that has a proximal end 22, a distal end 24, a graft material 14 associated with a series of external stents 16. The prosthesis 10 further has an internal sealing stent 16 d, and attachment stent 42, and a pivotable fenestration 12. FIG. 6 shows a partial close up view of the fenestration of FIG. 5. The pivotable fenestration 12 shown is an external fenestration 12 and has an inner perimeter 26 surrounding the fenestration 12, a band 28 of material surrounding the inner perimeter 26, and an outer perimeter 30 surrounding the band 26. As shown, a portion of the outer perimeter 30 lies between struts 32, 34 of the proximal most stent 16. Referring back to FIG. 5, the prosthesis 10 includes a non-pivoting fenestration 28 and a scallop 40 at the proximal end 22. As shown in these Figures and throughout the Figures, imageable markers 35, which may be viewed during and after placement of the prosthesis 10 may be placed at various locations on the prosthesis 10 to identify certain aspects of the prosthesis and their location during the implantation procedure and facilitate correct placement of the fenestrations 12, 38, scallop 40, the ends of the prosthesis and the like. For example, as shown in FIG. 6, markers 35 may be placed about the circumference of the outer perimeter 30. The markers 35 may be, for example, sewn or sutured to the graft material 14, as shown, or may be woven into the graft (not shown). The markers 35 also may be placed on the struts of one or more stents, for example, radiopaque marker tubes may be placed about one or more struts of the stent to indicate various areas of the stent graft. As shown, the markers 35 may be gold, however, any material that may be imaged by way of angiography, fluoroscopy, 3D imaging, MRI, or the like, may be suitable.

As further shown, particularly in FIGS. 6-7, the fenestrations 12, 38 and the scallop 40 may include a reinforcement frame 44 a, 44 b, 44 c, 44 d which may be sutured or otherwise attached to the graft 14. For example, in FIGS. 6-7, a reinforcement frame 44 a may be positioned about the outer perimeter 30. As shown in FIG. 6, a reinforcement frame 44 b may be positioned about the inner perimeter 26. As shown in FIG. 7, in particular, a reinforcement frame 44 c may be provided about the non-pivoting fenestration 38, and reinforcement frame 44 d may be provided about the perimeter of the scallop 40. The reinforcement frames 44 a, 44 b, 44 c, 44 d may be rings. In one preferred aspect, the reinforcement frames 44 a, 44 b, 44 c, 44 d are a wire that is sutured about the fenestration 12, 38, or scallop 40, to reinforce the fenestration or scallop. The reinforcement frames 44 a, 44 b, 44 c, 44 d may be made of any suitable material. One preferred material is a superelastic or shape memory material, such as nitinol. In another preferred embodiment, the reinforcement frames 44 a, 44 b, 44 c, 44 d may be made of radiopaque or other imageable material. In another embodiment the reinforcement frames 44 a, 44 b, 44 c, 44 d may be solid rings, or may be a wire that is looped about itself into a ring with unattached ends such that the ring may be expanded or contracted in diameter. Suitable frames are disclosed in U.S. patent application Ser. No. 10/962,632, filed Oct. 12, 2004, hereby incorporated by reference.

FIG. 8 is another partial and internal view of a fenestrated prosthesis 10 having two internal pivotable fenestrations 12. As shown in this aspect, a dome-like projection or frustoconical extension is formed within the prosthesis 10. A flexible frame 48 may be disposed about or within the band 28.

As shown throughout the Figures, inner perimeter 26, band 28, and outer perimeter 30 surround the pivotable fenestration 12 to create a hemisphere shaped or frustoconical extension or protrusion. The outer perimeter 30 may be affixed to the graft material 14 by any attachment method including suturing circumferentially about an aperture disposed through graft material 14. The band 28 may be comprised of the same or different biocompatible material as the graft material 14. For example, the second biocompatible material may have greater pliability than the first biocompatible graft material used for the tubular graft body.

The band 28 is sufficiently flexible to permit the fenestration 12 to move such that a branch stent disposed in the fenestration 12 may be oriented upwardly, downwardly, laterally, diagonally and the like. In some aspects, the band has up to about 180 degrees of freedom of movement relative to the surface plane of the prosthesis 10. Accordingly, the pivotable fenestration 12 allows the prosthesis 10 to be used with a variety of patients, due to its ability to adapt to the variance in the positioning of the diseased branch vessels. For example, if a body branch vessel is or becomes offset longitudinally or axially from a pivoting fenestration 12, the pivoting fenestration 12 will pivot the branch vessel prosthesis in the necessary direction and to the necessary degree to maintain the branch vessel prosthesis in place in the branch vessel.

FIG. 9 shows a partial, cross-sectional view of a portion of prosthesis 10 having a pivotable fenestration 12, inner perimeter 26 surrounding fenestration 12, band 28 surrounding inner perimeter 26 and outer perimeter surrounding band 28. The band 28 may be tapered such that the diameter decreases throughout its depth γ. The depth γ may be determined on the amount of movement required for the pivotable fenestration 12 during use and the ability to cannulate the targeted branch vessel. As the depth γ the amount of second biocompatible material used for the band 28 must also decrease, which limits the range of motion of the pivotable fenestration 12. Furthermore, the depth γ must be large enough in order to cannulate the targeted branch vessel. The depth γ may range from 3 to 10 mm, and preferably is about 6 mm. As shown, inner perimeter 26 has a diameter a that is smaller than the diameter β of outer perimeter 30. The diameter a inner perimeter 28 may be determined based on the average size of the targeted branch vessel. In this aspect, the prosthesis 10 may be used to repair a diseased renal artery. Accordingly, the average diameter of the inner perimeter 26 may be based on the average of the diameter α of the openings to the renal arteries, or about 6 mm.

The diameter β of the outer perimeter 30 may be determined based on the desired amount of movement and the desired patency of the prosthesis 10. As the diameter β of the outer perimeter 30 changes, the range of motion also changes. As the diameter β of the outer perimeter 30 decreases, the range of motion also decreases. Additionally, the diameter β of the outer perimeter 30 must be sized to prevent interference with circumferentially adjacent struts 32, 34 of the stents 16. Hence, the diameter β of the outer perimeter 30 may be at most about 15 mm in order to accommodate stents 16. The diameters α and β combined with depth γ provide the requisite amount of surface area for band 28 for the pivotable fenestration 12 to pivot during deployment of a secondary branch prosthesis into the fenestration 12 of after deployment based on dynamic changes to the anatomy.

FIGS. 10 and 11 show an internal view and an external view, respectively, of a pivotable fenestration 12 in an aspect where the fenestration is disposed within the lumen 18 of the prosthesis 10. FIG. 10 shows pivotable fenestration 12, inner perimeter 26, band 28, outer perimeter 30. The inner perimeter 26 and outer perimeter 28 a reinforcement frame 44 a is positioned about the outer perimeter 30. A reinforcement frame 44 b is positioned about the inner perimeter 26. As discussed above, the reinforcement frames 44 a and 44 b may be affixed to the 26 outer perimeter 30 and inner perimeter 26 may be, for example, sewn to the outer surface 20 of the graft material 14. Markers 35 are placed around the inner perimeter 26 in order to facilitate proper placement and alignment of a branch vessel prosthesis and the pivotable fenestration 12.

As shown in FIG. 10, the band 28 may be provided with a flexible frame 48. The flexible frame 48 provides support to the band 28 and helps to maintain the overall structure of the band 28 upon deployment within the diseased vessel. The flexible frame 48 also helps to maintain the patency of the pivotable fenestration 12. The flexible frame 48 allows to the band of material to reverse orientation and independently move between an interior surface of the prosthesis 10 and an exterior surface of the prosthesis 10 while the device is being deployed. In some embodiments, a physician may alter the orientation of the band 28 during deployment of the prosthesis 10 through the use of endoluminal devices, such as a guidewire catheter. The structure of the flexible frame 48 also prevents the pivotable fenestration 12 from everting or inverting (depending on the initial configuration) once the prosthesis 10 is deployed within the diseased vessel. The flexible frame 48 may be positioned on the band 28 either on the interior or exterior surface of the band 28. In this particular aspect, the flexible frame 48 is position on the interior surface of the band 28. The flexible frame 48 comprises a continuous wire formed into a plurality of support units 50 having a generally undulating shape comprising straightened struts 52 interconnected by outwardly facing apices or bends 54. The number of support units 50 may range from about 2 support units to about 10 support units.

In a preferred aspect, the flexible frame 48 has three support units 50. For example, as shown in FIG. 10, the outwardly facing apices 54 may abut or connect to the reinforcing frame 44 a of the outer perimeter 30. The outwardly facing apices may be, for example, sewn or sutured to reinforcing frame 44 a. The frame 48 may be bent to form a plurality of loops 56 a, 56 b, 56 c, 56 d. Loops 56 a, 56 b, 56 c are positioned in the troughs of the apices 52 of adjacent support units 50. Each loop 56 a, 56 b, 56 c may abut or connect to the reinforcing frame 44 b of the inner perimeter 26. The loops 56 a, 56 b, 56 c may be, for example, sewn or sutured to reinforcing frame 44 b. A loop 56 d may be positioned within an apex 54 of a support unit 50. Other aspects may comprise other configurations for the flexible frame 48, including, but not limited to, spirals, may be suitable. The flexible frame 48 may be heat set into the desired configuration prior to attachment to band 28. The flexible frame 48 may be comprised of an elastic or super elastic material, for example and without limitation, nitinol.

FIG. 11 shows an exterior view of a pivotable fenestration 12 where the fenestration is disposed within the lumen of the prosthesis. The pivotable fenestration 12 has an inner perimeter 26 surrounding the fenestration 12, a band 28 surrounding the inner perimeter 26, and an outer perimeter 30 surrounding the band 28. The inner perimeter 26 and outer perimeter 28 a reinforcement frame 44 a is positioned about the outer perimeter 30. Markers 37 may be sewn to around the circumference of the outer perimeter 30 in order to facilitate proper placement and alignment of the pivotable fenestration 12 and the targeted branch vessel.

FIG. 12 shows an embodiment of the band 28 formed from a protrusion 58 having a bubble like configuration as shown in FIG. 12, as described in co-pending U.S. patent application Ser. No. 12/548,120. The protrusion 58 is integrally formed with the body of the prosthesis 10 and is comprised of a second biocompatible graft material. The protrusion 58 may be created during the weaving process used to create the graft material 14. The prosthesis 10 may include, but is not limited to, weaves such as plain weaves, basket weaves, rep or rib weaves, twill weaves (e.g., straight twill, reverse twill, herringbone twill), satin weaves, and double weaves (e.g., double-width, tubular double weave, reversed double weave). Desirably, the weave comprises a tubular double layer weave. The fabric may be woven on a table loom, a floor loom, a jacquard loom, a counterbalance loom, a jack loom, or an upright loom. Desirably, the fabric is woven on a floor loom. The fabric may have any configuration possible, but preferably has warp and weft yarns. In one aspect, both the warp yarns and the weft yarns are textile yarns.

In order to create the protrusion 58, the number of warp yarns used while weaving the prosthesis 10 is increased in the region where the protrusion 315 is desired. While the additional warp yarns are weaved into the prosthesis 310, the number of weft yarns is kept constant. By increasing the number of warp yarns while holding the number of weft yarns constant, the second biocompatible graft material expands outwardly in the radial direction. The number of warp yarns is increased until a pre-determined diameter has been reached. Once the desired depth for the protrusion 58 is reached, the number of warp yarns introduced into the weaving apparatus is decreased until the number of warp yarns is equal to the number of weft yarns used to form the remainder of the prosthesis 10. A fenestration may be created through the protrusion 58 by applying heat to the center of the protrusion 10. Reinforcing frames may be added about the fenestration and adjacent to and surrounding the protrusion 58 to form the inner and outer perimeters 26, 30 of the prosthesis 10. Further, a flexible frame 48 may be attached to the protrusion 58 to maintain it in its desired extended configuration.

FIG. 13 depicts an exemplary prosthesis that has been deployed within a diseased vessel 70, such as the aorta. The prosthesis 10 comprises a tubular graft 72 having a sidewall 74 and a lumen 76 disposed longitudinally therein. The prosthesis 10 includes a first end 78 and a second end 80. The tubular graft 72 includes a plurality of rows 82 a, 82 b, 82 c of expandable stents circumferentially aligned affixed to the outer surface 84 of the tubular graft 72. A sealing stent 86 may be affixed to the first end 78 of the tubular graft 72 within the interior surface of the graft 72. The sealing stent 86 may be attached to the first end 78 of the tubular graft 72 by any attaching mechanism, for example and without limitation, suturing. Radiopaque markers 88 may be placed on the tubular graft 72 in order to assist with proper alignment of the tubular graft 72 when deployed within a patient. Fenestrations 90 may be disposed through the tubular graft 72. The distal end (not shown) of the prosthesis 10 may be bifurcated.

The tubular graft 72 also includes two internal pivotable fenestrations 12 that are in communication with the lumen 76. The tubular graft 72 may be preloaded onto a delivery device for deployment within a patient. The delivery device includes a sheath over the tubular graft 72 to keep the tubular graft 72 in a compressed state prior to deployment. The delivery device is placed over a guide wire and after checking the appearance and orientation of the device under x-ray, guide wires for each fenestration 12 are loaded through side ports in the handle of the delivery device. The delivery device is introduced over the guide wire, and advanced until a tapered tip of the delivery device is in the femoral artery and the radiopaque markers indicating the fenestrations 12 are at a level of the appropriate arteries. A sheath is advanced over the guide wire for each fenestration 12 through each side port on the handle of the device. Once the sheaths for the fenestrations 12 are in position, the tubular graft 72 can be advanced to its correct position and orientation for deployment. The tubular graft 72 is deployed by withdrawing the sheath covering the graft over the pusher. The operator can perform angiography and adjust the placement of the tubular graft 72 if necessary. Deployment is continued until the tubular graft 72 is fully unsheathed. The sheaths for the fenestrations 12 are advanced over the wires until they are at a level of the lower margin of the fenestration 12. The sheaths for the fenestrations 12 are punctured and a guide wire is advanced through each sheath. A catheter is advanced over the guide wires, and once the catheters are in the target vessels, a stiffer wire replaces the guide wire. The sheaths for the fenestrations 12 are then advanced into the target vessels and branch vessel prostheses are advanced through the sheath and placed in the desired position.

FIG. 13 illustrates in accordance with the procedure described above branch vessel prosthesis deployed through each of the two fenestrations 12. Branch vessel prostheses 92, 94 are formed from biocompatible materials and may comprise covered stents. Alternatively, they may comprise bare stents. The covered or bare stents may be either self-expanding or balloon expandable. In one aspect the branch vessel stent may have both self expanding and balloon expandable components. For example, the branch vessel stent may have an end not shown for placement within the fenestration this is upon deployment, either self-expanding or by balloon expansion. If the branch vessel stent is a covered stent, the graft material used may comprise one or more of the biocompatible materials are discussed above.

As shown in FIG. 13, the branch vessel prostheses 92, 94 are deployed into branch vessels 96, 98 such as the right and left renal arteries. As shown in Figure, the right opening 100 is not completely aligned with the right branch vessel 92. Particularly, the right branch vessel 96 is positioned lower than the corresponding left branch vessel 98. To accommodate placement of the branch vessel prosthesis 92 into the right branch vessel 96, the pivotable fenestration 12 provides the requisite flexibility and ability to pivot required for the branch vessel prosthesis 92 to deploy into the desired position.

FIGS. 14 and 15 show a branch vessel prosthesis 92 deployed in a secondary branch vessel in greater detail. As shown in FIG. 14, the branch vessel prosthesis 92 is deployed within the right branch vessel 96, which is positioned lower than its corresponding left branch vessel. Alternatively, as shown in FIG. 15, the branch vessel prosthesis 92 is deployed within the right branch vessel 102, which is positioned higher than its corresponding left branch vessel. The pivotable fenestration 12 allows for pivoting motion to accommodate the offset position of the right branch vessel 98, 102 and provide access to the right branch vessel 96, 102 through the use of a delivery device, such as a catheter.

Once a catheter is placed within right branch vessel 96, 102, the branch vessel prosthesis 92 may be deployed within the right branch vessel 96, 102. The branch vessel prosthesis 92 may be balloon expandable or self-expandable. In this aspect, the branch vessel prosthesis 92 is balloon expandable. Once the secondary branch prosthesis 146 is deployed in the right branch vessel 96, 102, the end of the branch vessel prosthesis 92 remaining within the interior surface of the prosthesis 10 may be flared in order to provide a proper seal between the fenestration 12 and the branch vessel 96, 102.

With reference to FIGS. 16 and 17, in another embodiment, the prosthesis 10 can include the tubular graft 72 that includes a pocket 200 disposed near each of the fenestrations 12. As described in further detail below, the pocket 200 can assist in sealing one of the fenestrations 12 in the event that one of the fenestrations 12 cannot be used to cannulate the corresponding branch vessel 96 or 98, or one of the branch vessels 96 or 98 is not present.

In some instances, the patient's anatomy may not include one of the branch vessels 96 or 98 at the location of the fenestration 12, or one of the branch vessels 96 or 98 cannot be cannulated. For purposes of discussion, these branch vessels will be referred to as an unused branch vessel 202, and the corresponding fenestration will be referred to as an unused fenestration 212. In this situation, the unused fenestration 212 is preferably sealed to prevent blood from flowing or leaking out of the graft through the unused fenestration 212.

As described above, the graft 72 can include the pocket 200. The pocket 200 can be formed on the exterior surface of the graft 72. The pocket 200 can made from the same material as the graft 72, or another suitable graft material. The pocket 200 includes a main body portion or flap 214 that is preferably sewn or otherwise attached to the exterior surface of the graft 72. When attached to the graft 72, the pocket 200 can define a pocket opening 216 to a pocket cavity 217. The opening 216 can be disposed adjacent the unused fenestration 212. Thus, the pocket 200 can define a direction in reference to the direction of the opening 216 relative to the cavity 217. In another form, the pocket 200 can be disposed further away from the unused fenestration 212.

The graft 72 can include a wire 218 similar in construction to a typical guidewire. The wire 218 can be installed on the graft 72 for deployment along with the rest of the prosthesis 10 such that the wire 218 is “preloaded.” The wire 218 extends through the graft lumen and out of the unused fenestration 212. The wire 218 will extend from the unused fenestration 212 and into the pocket 200 within the cavity 217. The wire 218 can be attached to the exterior surface of the graft 72 that is covered by the flap 214 (FIG. 16), or the wire 218 can extend back through the graft 72 and into the graft lumen (FIG. 20).

With reference to FIG. 17, to seal the unused fenestration 212, the branch vessel prosthesis 92 can be inserted over the wire 218 in a manner similar to that used to deliver the branch vessel prosthesis 92 to the standard fenestration 12

As the unused fenestration 212 may not be known prior to delivery of the graft 72 within the patient's body, each of the fenestrations 12 can include the pocket 200 and preloaded wire 218 on the prosthesis. Use of the wires 218 to deliver the branch vessel prosthesis 92 is elective, depending on whether or not the fenestration 12 becomes an unused fenestration 212 due to the patient's anatomy. Thus, in the event the use of either pocket 200 is unnecessary and the fenestrations 12 will be used in a standard manner, the wires 218 can be withdrawn from the prosthesis 10, and delivery of the branch vessel prosthesis 92 through the fenestrations 12 can be performed as previously described. For purposes of further discussion, only one pocket 200 and wire 218 will be described.

As described above, the pocket 200 is disposed on the outer surface of the graft 72. The pocket 200 is preferably disposed proximal to the unused fenestration 212, so the delivery of the branch vessel prosthesis 92 in the proximal direction along the wire 218 can be performed in a typical manner.

Similar to the description of the graft 72 previously described, the graft 72 can include a sealing stent 220 attached to the inner surface of the graft 72, along with external stents 222 attached to the outer surface. The portion of the graft 72 surrounding the sealing stent can be referred to as the sealing portion 224, and the portion of the graft having external stents 22 can be referred to as the non-sealing portion 226. However, this reference to the non-sealing portion 226 should not be interpreted as a portion that cannot seal; rather, the reference is intended to distinguish this portion having the external stents 222 from the portion that surrounds the sealing stent 220.

With reference to FIGS. 18 and 19, the pocket 200 is preferably disposed on the non-sealing portion 226 to limit the pocket 200 from extending over the sealing portion 224. However, in some forms, the fenestrations 12 can disposed near the sealing portion 224, such that the pocket 200 being proximal to the fenestration 12 could result in some overlap with the sealing portion 224, as shown in FIGS. 17 and 18.

With reference to FIG. 19, to limit the amount of overlap, the pocket 200 can be oriented in a direction transverse to the longitudinal direction of the graft 72. In some forms, the pocket 200 can be oriented perpendicular to the longitudinal direction of the graft 72.

In some cases, it may not be desirable to orient the pocket 200 in a transverse direction, or it may be desirable to locate the pocket over the sealing portion 224 of the graft 72, as shown in FIGS. 17 and 18. In these cases, the pocket 200 can be preferably crushed to substantially flatten the pocket 200, and the branch vessel prosthesis 92 inserted therein, to make the outer profile of the sealing portion 224 smoother relative to a non-flattened pocket so that the pocket 200 and prosthesis 92 do not interfere with the sealing portion 224. In this approach, the pocket 200 and prosthesis 92 can be crushed using a balloon catheter in a manner known in the art after installation and sealing has occurred.

Having described the general structure and alternative arrangements of the graft 72 having the pocket 200 thereon, the use of the pocket 200 with the graft will described in further detail.

The graft 72 can be delivered to the body vessel of the patient in the manner described previously leading up to cannulation of the renal arteries. The graft 72 will have the wires 218 preloaded thereto so that the wires 218 extend within the graft lumen, through the fenestrations 12, and into the pocket 200, as shown in FIG. 16.

With reference to FIG. 17, upon determining that one of the fenestrations 12 is an unused fenestration 212, either due to the lack of an artery at the location of the fenestration 12 or an inability to cannulate the artery, the branch prosthesis 92 can be inserted over the wire 218. The branch prosthesis 92 can be inserted over the wire 218 in the proximal direction toward the unused fenestration 212 in a manner known in the art. The prosthesis 92 can then be inserted through the unused fenestration 212, where it will directed through the opening 216 and into the cavity 217 of the pocket 200.

Upon being inserted into the cavity, the branch prosthesis 92 can be balloon expanded in a manner known in the art to the seal the unused fenestration 212 as if it were a typical fenestration 12 that is being sealed to provide blood flow to an artery. The prosthesis 92 will expand into engagement with the unused fenestration as well as the pocket 200. The unused fenestration 212 is now sealed, and blood flowing through the prosthesis 92 will be stopped from flowing into the body vessel by the pocket 200.

Upon completion of the sealing process, the wire 218 can be withdrawn in the same manner as a guidewire.

As stated above, the use of the pocket 200 is elective, such that in the event that the artery corresponding to the location of the pocket 200 can be cannulated, the wire 218 can be withdrawn from the pocket 200 and the pocket can remain unused. In this form, the wire 218 could be reused as a guidewire for guiding the branch prosthesis 92 into the corresponding renal artery, similar to the cannulation procedure previously described. FIG. 20 shows the graft 72 implanted in the body vessel, with branch vessel 96 cannulated and branch vessel 98 non-cannnulated. The branch extension prostheses 92 are installed through one fenestration 12 to cannulate the branch vessel 96 and through the unused fenestration 212 into the pocket 200.

In some cases, withdrawal of the wire 218 can leave a small hole in the graft 72 where the wire 218 was attached to the exterior surface of the graft 72, or if the wire 72 extended back into the graft lumen after extending into the pocket 200. However, the sealing arrangement between the unused fenestration 212, the branch prosthesis 92, and the pocket 200 will prevent the resulting hole from being exposed, thereby substantially limiting leaking through the hole. However, the wire 218 could also be anchored to the exterior surface of the graft 72 using an adhesive, a suture, or the like that can be configured to allow the wire to break away from the surface in response to pulling on the wire 218. In one form, the small hole caused by the wire 218 could be self-sealing, by natural blood clotting (thrombosis), a closeable flap, or the like.

As described above, in some cases, it is desirable to crush the pocket 200 and the prosthesis 92 sealed thereto if the pocket 200 is disposed over the sealing portion 224 of the graft 72. In this case, a balloon catheter can crush the pocket 200 and the prosthesis 92 in a manner known in the art so that it does not interfere with the sealing portion 224.

The above description applies to pockets 200 having varying orientations, including longitudinally running orientations as well as orientations transverse to the longitudinal direction of the graft 72. The wire 218, being extended into the pocket 200, will cause the prosthesis 92 to be routed into the pocket 200 despite a transverse orientation. Thus, the same method can be applied to grafts 72 having various pocket orientations, thereby simplifying the installation of the graft 72 for the user.

The above description has generally been directed toward the pivot fenestration described herein. However, it will be appreciated that the pocket 200 can be used on grafts having other types of fenestrations or passageways that are not used for their typical branching purposes. In these cases, the pocket 200 can be similar disposed near the passageway, with the wire 218 extending into the pocket from the graft lumen, and the branch prosthesis 92, or similar branch extension, can be inserted over the wire as if it were being delivered typically. The branch prosthesis 92 can be inserted along the wire 218 into the pocket where it can be expanded in a manner known in the art to seal the branch with the passageway as well as the pocket 200.

Throughout this specification various indications have been given as to preferred and alternative examples and aspects of the invention. However, the foregoing detailed description is to be regarded as illustrative rather than limiting and the invention is not limited to any one of the provided aspects. It should be understood that it is the appended claims, including all equivalents, that are intended to define the spirit and scope of this invention. 

I claim:
 1. A prosthesis system, comprising: a graft having a tubular body with a proximal and distal end, a lumen between the proximal and distal ends, and a surface comprising a first biocompatible material; at least one passageway extending through a sidewall of the graft; a pocket spaced away from the passageway and disposed on an exterior surface of the graft, the pocket having an open end defining an opening, a closed end, and a cavity extending between the open end and the closed end, the open end being open to an exterior of the graft, wherein the pocket is configured to receive a tubular extension prosthesis extending between the pocket and the passageway to prevent fluid flow through the passageway to the exterior of the graft; and a wire extending through the lumen of the graft and out from the lumen through the passageway, from the passageway through the opening, and from the opening into the cavity and engaging the surface of the graft that is covered by the pocket.
 2. The prosthesis system of claim 1 further comprising a tubular extension prosthesis extending between the pocket and the passageway, wherein the tubular extension prosthesis sealingly engages the passageway and the pocket.
 3. The prosthesis system of claim 1, wherein the pocket comprises the first biocompatible material.
 4. The prosthesis system of claim 1, wherein the pocket is oriented longitudinally along the graft.
 5. The prosthesis system of claim 1, wherein the pocket opening faces the passageway.
 6. The prosthesis system of claim 1, wherein the pocket is oriented transverse to a longitudinal axis of the graft.
 7. The prosthesis system of claim 1, wherein the wire extends through the graft material at a location where the wire engages the surface of the graft that is covered by the pocket and back into the graft lumen.
 8. The prosthesis system of claim 1 further comprising an inner stent ring attached to an inner surface of the tubular graft, wherein the pocket is disposed distally from the inner stent ring.
 9. The prosthesis system of claim 1, wherein the passageway comprises a pivot fenestration.
 10. A system for sealing an unused passageway in a graft, the system comprising: an expandable tubular graft having proximal and distal ends and a lumen between the proximal and distal ends; at least one passageway extending through a sidewall of the tubular graft; a pocket spaced away from the passageway and attached to an external surface of the tubular graft, the pocket defining an opening at a first end and being substantially closed at a second end; a wire extending through the lumen and out of the lumen through the passageway and into the opening of the pocket and toward the second end that is substantially closed; and an expandable tubular branch extension disposed over the wire between the pocket and the passageway to prevent fluid flow through the passageway to the exterior of the graft.
 11. The system of claim 10, wherein the tubular graft includes a sealing portion at the proximal end.
 12. The system of claim 11, wherein the pocket is disposed on a portion of the graft separate from the sealing portion.
 13. The system of claim 11, wherein the pocket is disposed at least partially over the sealing portion.
 14. The system of claim 10, wherein the tubular branch extension is expanded into sealing engagement with the pocket and the passageway.
 15. The system of claim 10, wherein the tubular branch extension sealingly engages the pocket and the passageway and the pocket and tubular branch extension are substantially crushed.
 16. A method for sealing an unused passageway in a tubular prosthesis, the method comprising: delivering a tubular graft to a body vessel, the tubular graft having proximal and distal ends and a lumen between the proximal and distal ends, the graft further having a passageway in a sidewall thereof, a pocket spaced away from the passageway, and disposed on an exterior surface of the graft, the pocket having an open end and a closed end and a cavity extending between the open end and the closed end, the pocket configured to receive a tubular graft extension extending between the passageway and the pocket, and a wire extending through the lumen of the graft and out of the lumen through the passageway and into the pocket cavity from the open end of the pocket toward the closed end of the pocket; delivering an expandable tubular graft extension along the wire toward the pocket; engaging the tubular graft extension with the pocket and the passageway; expanding the tubular graft extension; and sealing the tubular graft extension to the pocket and the passageway.
 17. The method of claim 16 further comprising withdrawing the wire from the pocket through the tubular graft extension.
 18. The method of claim 16 further comprising, in response to sealing the tubular graft extension to the pocket and the passageway, crushing the pocket and graft extension.
 19. The method of claim 16, wherein the pocket is disposed proximally from the passageway.
 20. The method of claim 16, wherein the pocket and the wire are aligned transverse to a longitudinal axis of the tubular graft. 